Izjava stranog funkcionera pl /statement for identification of foreign functionary le



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IZJAVA stranog funkcionera PL

/STATEMENT for identification of foreign functionary LE/
Šifra: OBR-181

Verzija: 3

Strana: /


Poštovani / Dear Sir,
U cilju uspostavljanja i razvijanja poslovne saradnje, a na osnovu člana 30. Zakona o sprečavanju pranja novca i finansiranja terorizma („Službeni

glasnik“ Republike Srbije br.20/2009, 72/2009, 91/2010 i 139/2014) i Odluke o smernicama za procenu rizika od pranja novca i finansiranja terorizma

(„Službeni glasnik“ Republike Srbije br.46/2009 i 104/2009 ) najljubaznije Vas molimo da popunite podatke u sledećoj izjavi.

With aim of establishing and developing our business cooperation and pursuant to Article 30 of the Law on prevention of money laundering and

terrorism financing (Official Gazette of RS 20/2009, 72/2009, 91/2010 and 139/2014) and Decision on the guidelines for assessing the risk of money

laundering and terrorism financing (Official Gazette of RS 46/2009 and 104/2009), please provide us with the data requested in the following

statement.

Zahvaljujemo na razumevanju i saradnji! / Thank you kindly for your understanding and cooperation!

Vaša JUBMES banka a.d.Beograd / Yours sincerely, JUBMES banka a.d. Beograd/


IZJAVA / STATEMENT

Ja (ime, ime jednog roditelja, prezime)/

I (name, name of one of the parents

and surname)


     

Rođen/a (datum i mesto)/

Born (date and place of birth)



     

Država boravišta/porekla /

State of residence/origin



     

Država prebivališta /
State of abode

     

Broj i vrsta važećeg ličnog dokumenta/
Valid personal ID type and number

     

Datum i mesto izdavanja važećeg ličnog dokumenta/

Date and place of valid personal ID issuance



     







U pravnom licu (poslovno ime, adresa i sedište pravnog lica) /

I state hereby that in the following legal entity


(business name, address of the head-office):

     







izjavljujem da imam status/ I hold the status of:

 Zastupnika/ Agent

 Punomoćnika/ Proxy

 Prokuriste/ Procurator

 Stvarnog vlasnika/ Beneficial owner *
















Izjavljujem / I hereby state as follows (Please indicate):

1.

Ja sam strani funkcioner / I am a foreign functionary**

 Da / Yes

 NE/ No

2.

Član sam uže porodice stranog funkcionera/ I am a member of the immediate family of a foreign functionary **

 Da / Yes

 NE/ No

3.

Uži/bliži sam saradnik stranog funkcionera/ I am a close associate of a foreign functionary **

 Da / Yes

 NE/ No

Ako ste na prethodna pitanja odgovorila sa NE, molimo da se potpišete. Potpisom potvrđujem da su napred dati podaci u ovoj izjavi tačni i istiniti./

If your answers to the aforesaid questions are negative, please sign this statement. I state by my signature that all replies, data and information contained herein are true and correct.
Popunjavanjem i podnošenjem obrasca „Izjava o stranom funkcioneru“ smatra se da je klijent upoznat sa svrhom i uslovima prikupljanja i dalje obrade

podataka, kao i da je dao punovažni pristanak da Banka izvrši obradu podataka o ličnosti samo u svrhe sprovođenja radnji i mera iz člana 30. Zakona o

spečavanju pranja novca i finansiranja terorizma ( Sl.gl. RS br. 20/2009, 72/2009, 91/2010 i 139/2014)

/When the client submits the completed form „Statement of the foreign functionary“ it shall be considered that he has been acquainted with the purpose and conditions of data collecting and processing, as well as that he gave his valid consent to the Bank to process his personal data only in order to implement actions and measures governed by the Article 30 of the Law on prevention of money laundering and terrorism financing (Official Gazette of RS nos. 20/2009, 72/2009, 91/2010 i 139/2014).

Pristanak se može opozvati, u pisanoj formi ili usmeno na zapisnik. U slučaju opoziva, Banka će postupiti u skladu sa Zakonom o zaštiti podataka o

ličnosti (Sl.gl. RS br. 36/2011 i 139/2014)/

The client may withdraw his consent by submiting his written notice or by making oral statement to Bank's officer, who will write it down. In the case of consent withdrawal the Bank shall act in conformity with the Law on protection of personal data (Offical Gazette nos. 36/2011 i 139/2014). The client may withdraw his consent by submiting his written notice or by making oral statement to Bank's officer,who will write it down. In the case of consent withdrawal the Bank shall act in conformity with the Law on protection of personal data (Offical Gazette nos. 36/2011 i 139/2014).


U/In

     

Ime i prezime/

Name and surname



     

(Mesto i datum / Place and date)

Potpis/

Signature:






Napomena/ Note:


* Stvarni vlasnik pravnog lica je: - fizičko lice, imalac 25% (odnosno 10%) ili više poslovnog udela, akcija, prava glasa ili drugih prava u prava, na osnovu kojih učestvuje u upravljanju pravnim licem, odnosno učestvuje u kapitalu pravnog lica ili ima dominantan položaj u upravljanju imovinom pravnog lica; - fizičko lice, koje privrednom društvu posredno obezbedi ili obezbeđuje sredstva i po tom osnovu ima pravo da bitno utiče na donošenje odluka oragana upravljanju privrednim društvom prilikom odlučivanja o finansiranju i poslovanju.

Beneficial owner of the entity is a natural person who holds a minimum of 25% (i.e. 10%) of the business share, shares, voting or other rights empowering him to participate in the legal entity’s management, or who holds legal entity’s share capital or has a dominant position in the legal entity’s assets management; as well as a natural person who has provided or provides funds to a company, in an indirect manner, which entitles him to significantly influence the company’s decisions concerning financing and business operations.

** Strani funkcioner je svako fizičko lice koje obavlja ili je u poslednjoj godini obavljalo javnu funkciju u stranoj državi ili u međunarodnoj organizaciji i to funkciju: šefa države i/ili vlade, član vlade i njegovog zamenika odnosno pomoćnika; izabranog predstavnika zakonodavnog tela; sudije vrhovnog i ustavnog suda ili drugog sudskog organa na visokom nivou, protiv čije presude, osim u izuzetnim slučajevima, nije moguće koristiti redovni ili vanredni pravni lek; člana računskog suda, odnosno vrhovne revizorske institucije i saveta centralne banke; ambasadora, otpravnika poslova i visokog oficira oružanih snaga; člana upravnog i nadzornog organa pravnog lica koji je u većinskom vlasništvu države, uključujući članove njegove uže porodice ili bliže saradnike:

Član uže porodice stranog funkcionera je bračni ili vanbračni partner, roditelji, braća i sestre, deca i njihovi bračni ili vanbračni partneri;

Bliski saradnik stranog funkcionera je svako fizičko lice koje ostvaruje zajedničku dobit iz imovine ili uspostavljenog poslovnog odnosa ili ima bilo koje druge poslovne odnose sa stranim funkcionerom.

Foreign functionary is a natural person who performs at present, or performed in the previous year for a foreign country or international organisation a public function of: leader of the state and/or government, member of government, his deputy or associate; elected representative of the legislative authority; judge of the supreme or constitutional court or another high juridical authority, against whose verdict ordinary or extraordinary legal remedy cannot be requested, unless in exceptional cases; member of a court of auditors or a major auditor’s institution and the central bank’s council; ambassador, charge d’affaires or high military officer; member of the managing board or supervisory committee or the legal entity in majority owned by the government. This definition includes also members of immediate family of the foreign functionary and a close associate of the foreign functionary.

Member of immediate family of the foreign functionary is his spouse or unmarried companion, parents, brothers and sisters, children and their spouses or unmarried companions;

Close associate of the foreign functionary is a natural person sharing mutual profit derived from the property or business relationship or has any other form of close business relations with foreign functionary.

U slučaju da ste na neko od napred navedenih pitanja odgovorilI sa DA, molimo Vas takođe da odgovorite na sledeća pitanja (4-7)/

If any of the aforesaid questions is replied affirmatively, please answer the following questions too (4-7):



4.

Koju javnu funkciju, u kojoj stranoj državi ili međunarodnoj organizaciji, obavljate ili ste obavljali u poslednjih godinu dana?

What public function, in what foreign country or international organisation do you perform or you have performed in the previous year?



     

5.

U kom porodičnom statusu ste sa licem koje je strani funkcioner?

What is your family relationship with the foreign functionary?



     

6.

U kojoj vrsti poslovne saradnje ste sa licem koje je strani funkcioner (opišite ukratko oblik i način poslovanja)?

What is the nature of your business cooperation with the foreign functionary (please describe operations in short)?



     

7.

Izvor (poreklo) imovine i sredstava koja su ili će biti predmet našeg poslovnog odnosa i/ilii vaših transakcija?

What is the source of property and funds which will be a matter of our business relationship and/or your business transactions?



     

Popunjavanjem i podnošenjem obrasca „Izjava o stranom funkcioneru“ smatra se da je klijent upoznat sa svrhom i uslovima prikupljanja i dalje obrade

podataka, kao i da je dao punovažni pristanak da Banka izvrši obradu podataka o ličnosti samo u svrhe sprovođenja radnji i mera iz člana 30. Zakona o

spečavanju pranja novca i finansiranja terorizma ( Sl.gl. RS br. 20/2009, 72/2009, 91/2010 i 139/2014)/When the client submits the completed form

„Statement of the foreign functionary“ it shall be considered that he has been acquainted with the purpose and conditions of data collecting and

processing, as well as that he gave his valid consent to the Bank to process his personal data only in order to implement actions and measures

governed by the Article 30 of the Law on prevention of money laundering and terrorism financing (Official Gazette of RS nos. 20/2009, 72/2009, 91/2010

i 139/2014).

Pristanak se može opozvati, u pisanoj formi ili usmeno na zapisnik. U slučaju opoziva, Banka će postupiti u skladu sa Zakonom o zaštiti podataka o

ličnosti (Sl.gl. RS br. 36/2011 i 139/2014)/ The client may withdraw his consent by submiting his written notice or by making oral statement to Bank's

officer, who will write it down. In the case of consent withdrawal the Bank shall act in conformity with the Law on protection of personal data (Offical

Gazette nos. 36/2011 i 139/2014). The client may withdraw his consent by submiting his written notice or by making oral statement to Bank's officer,

who will write it down. In the case of consent withdrawal the Bank shall act in conformity with the Law on protection of personal data (Offical Gazette

nos. 36/2011 i 139/2014).


Potpisom potvrđujem da su svi napred dati podaci u ovoj izjavi tačni i istiniti.

I state by my signature that all replies, data and information contained herein are true and correct




U/In

     

Ime i prezime/

Name and surname



     

(Mesto i datum / Place and date)

Potpis/

Signature:






POPUNJAVA BANKA

Ime i prezime zaposlenog:

     

Mesto, datum i vreme:

     




Potpis









Saglasnost:




Ime i prezime odgovornih lica banke:

Potpisi:




     




     




     




     







Mesto i datum

     






Bulevar Zorana Đinđića 12111070 BeogradPAK 190311Tel.: 2205-500Fax: 311-0217



E-mail: jubmes@jubmes.rsWeb: www.jubmes.rsSWIFT: JMBNRSBG


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